SPECIAL REPORT: Healthcare in Bolton

HEALTH and social care is set to be transformed in Bolton with hospital resources being invested in the community — but GP’s have warned the town’s surgeries are not ready for the shake-up.

The new “integrated” system is designed to rescue cash-strapped health and social care services, buckling under the growing needs of the ageing population.

It will see Bolton Council pool resources with the hospital, health commissioners, mental and healthcare services to provide health and social care “closer to home.”

The new system is designed to target people most likely to be admitted to hospital by treating those with long-term health problems earlier.

It comes as announced plans to create up to five “super hospitals” in Greater Manchester.

The changes are part one of the biggest shake-up of NHS Services Greater Manchester has ever seen.

Bosses at the Royal Bolton are proposing to invest heavily in maternity, children and obstetrics services as well as the A&E department.

Wigan Infirmary is also on the shortlist of potential ‘super hospitals’, along with Stepping Hill in Stockport and Wythenshawe.

Manchester Royal Infirmary, Salford Royal Hospital and Royal Oldham Hospital are already confirmed as “super hospitals”.

Under the new integrated healthcare plans, teams are in the process of identifying patients most at “at risk” of being admitted to hospital with long-term conditions, such as diabetes, or younger people with “complex” lifestyles, such as drug and alcohol addiction or unemployment.

Yet concerned GP’s say surgeries are already overwhelmed and do not currently have the capacity to deliver extra services.

Dr Wirin Bhatiani, chairman of NHS Bolton Clincal Commissioning Group (CCG), said the integrated system needs investment before it is rolled out across all practices.

He added: “Currently, all GPs are very busy managing the day to day demands in surgeries and can’t see how they can find the time to also focus on the most vulnerable people to keep them well and out of hospital.

“It’s a priority for Bolton CCG to support practices to both improve access for patients but also free up time GPs time to spend longer planning the care of those patients in greatest need.

“This needs investment and is part of our financial plans for this year. We will be making initial decisions on funding and supporting GP surgeries this month and have further ideas we are working up”.

The integrated system will be delivered by Bolton Council, Bolton CCG, the Bolton NHS Foundation Trust and Greater Manchester West Mental Health NHS Foundation Trust (GMW).

The CCG and Bolton Council will invest £750,000 to fund 21 additional staff to support GP practices across Bolton this year.

The staff will include social workers, nurses, physiotherapists, occupational therapists, mental health workers, pharmacists and support staff.

Health chiefs are running a pilot scheme at two GP practices in Westhoughton with a view to roll it out across all GP practices in 2015.

It is expected to benefit 1,000 patients in the next year.

HOW WILL IT WORK?

ONLY patients deemed “at risk” of being admitted to hospital — such as the elderly or people with ongoing health problems — will be affected by the new integrated system.

The new model has been designed around the needs of 20,000 to 30,000 people built from “clusters” of GP practices.

There will be 10 clusters and these will be “risk stratified” using a tool currently being piloted in Great Lever.

This is a way of categorising GP practice populations by identifying patients with the greatest health needs who are therefore most likely to be admitted to hospital in the future.

So far GP’s have identified 19,334 people as “at risk” in Bolton.

Each of these will be assigned a single key worker, who will co-ordinate all their health and care needs. The type of key worker, such as a nurse or carer, is yet to be specified by health chiefs.

This key worker will hold meetings with what health chiefs have termed a “multi-disciplinary” team, which will include a GP, a practice nurse, a district nurse, physiotherapist, an occupational therapist, a pharmacist, a social worker and a mental health worker.

Adrian Crook, director of adult social care at Bolton Council, said: “There are two reasons we are doing this.

“One is for the quality of care. We need care that is simpler to access and a more streamlined way of delivering services to the elderly.

“The problem at the moment is lots of people are going into people’s homes for different purposes. It can be very overwhelming for the people and when we have spoken to the elderly, they say they would rather be visited by one person.

“The second reason is the demographic and cost pressures of caring for people with long-term conditions. All the while we are trying to make our resources meet that bigger demand.”

The council and Bolton CCG have already started integrating services by reducing intermediate care beds and mental health beds in the Royal Bolton in favour of caring for people in their own homes.

Su Long, chief officer at Bolton CCG, added: “We need to help health and social care services deal with long-term problems early on and help bring the demand for hospital services down.

“Often people end up in hospital because the appropriate care was not available.”

THE IMPACT ON THE HOSPITAL WARDS are already shutting at the Royal Bolton Hospital in order to make the savings to invest in the community care services.

Twenty-eight beds were lost last month when B3 ward was shut and a further 24 due to shut this year as part of the cut-backs.

Health chiefs stress there is no new money available for health and social care in Bolton and that the redesign is essential if the NHS is to balance its books.

The Government has committed to making £3.8 billion available through a pooled budget arrangement between local authorities and NHS organisations. It is known as the Better Care Fund.

The first step of investment for Bolton will be diverting money from the council and Bolton CCG’s budget to invest £10.8 million in 2014/15 with a further £21.2 million in 2015/16 into integrated care.

The fund will mean a cut of about £7.6 million in the Royal Bolton Hospital’s budget — but there will be a £4 million investment in its community-based services.

Overall the Bolton NHS Foundation Trust — which is responsible for hospital and some community services — will have to make savings of £3.8 million.

This could equate to the closure of three wards in total at the hospital in order to invest in community care.

Heather Edwards, head of communications at the Bolton NHS Foundation Trust, said: “It is important to stress that the idea behind integration is that hospital is not always the best place for patients. Many could be cared for more effectively in the community.”

The Government was rumoured to have halted the roll out of the Better Care Fund but Department of Health officials insist it will go ahead.

A Department of Health spokesman added: “Successive governments and health leaders have talked about joining up health and social care for decades — the Better Care Fund is a major step to making this a reality and transforming the way people are cared for closer to home.

“We have set aside time to make sure all areas have developed comprehensive plans for joined-up care. The Better Care plans start from April 2015, and we asked for early versions to be completed a year in advance so we could review them, check their level of ambition and test how they would be delivered. This is what is happening now.”

WHAT DO THE CLINICIANS THINK?

DOCTORS at the Royal Bolton Hospital say that “in principle” they are behind strengthening community services and caring for more people in their own homes.

But concerns have been raised about the burden the new system will place on staff working in the community — such as district nurses — and the speed at which the Government expects the new system to be rolled out.

Dr Kevin Jones is a consultant physician in acute medicine at the Royal Bolton Hospital.

He said: “I don’t think there’s any doubt that patients are coming to the hospital when it is not always the best place for them.

“At the moment 75 per cent of NHS spending goes on hospital care so there has to be a shift of the resources into primary care.

“Patients need to understand this but perhaps they come to hospital because they feel that there is not a better alternative.

“If an elderly patient breaks their arm and has no-one to help them at home, they will often come to hospital because they have no other option. After 10pm at night, there is currently no service available for people. Care needs to be responsive for people in their own home.

“Also people know that the hospital is a safety net.

“A huge amount of education needs to be done here. People want to go to A&E because they know they will be treated within four hours, rather than waiting four days for a GP’s appointment.”

Dr Jones conceded there was concern among hospital staff and GP’s about the level of investment into integrated care.

He added: “There are concerns on both sides about the speed at which integration is happening. There needs to be a huge amount of investment in primary care in order for this to happen.”

CONCERNS CRITICS of the shake-up say providing care in people’s homes could put patients at risk and increase the burden on carers.

Collaboration between services competing for NHS and council contracts could also be problematic, according health unions.

Karen Reissman, secretary of Bolton Save our Health Service campaign, said: “Collaboration between different agencies is very difficult when they are all bidding to provide the same service.

“The problem with multi-disciplinary working is that patients lose access to the specialist areas which would have previously been provided by people across health and social care.

“These key workers will just become case managers.”

Yet some argue this is the only way forward if health and social care is to adapt to dwindling services.

Former councillor Andy Morgan — who sat on the Health Overview and Adult Social Care Scrutiny Committee — said: “The intent and aspiration of integrating services is right. To do nothing with the resources we have is not an option.

“But the community teams must be resourced properly otherwise we are doomed to fail.”

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